IAS: Ramp Up of Adult Circumcision Urged to Prevent AIDS

Action Points

Explain to interested patients that the recommendations of these researchers apply only in areas of high HIV prevalence.

Be ready to counsel patients on sexual behaviors and note that circumcision only offers partial protection against HIV infection.

Remember that these comments come from an address at a plenary session of a conference and have not undergone critical scrutiny of the peer-review process or been published in a peer-reviewed journal.

SYDNEY, July 26 -- Making circumcision widely available to adult men in regions of the world where HIV infection is highly prevalent will save millions of lives and should be undertaken immediately, researchers urged here.

"In circumcision we have a proven efficacious HIV prevention intervention," said Robert Bailey, Ph.D., professor of epidemiology at the University of Illinois at Chicago.

Years of studies, including well-controlled randomized clinical trials have shown male circumcision reduced HIV infection by more than 50%, he told attendees at a plenary session at the International AIDS Society meeting.

And did so at a reasonable cost and without resulting in a major increase in risky behavior among the men who had been circumcised.

"One cannot help but contemplate that if it were a drug or a compound or a shot with a fancy label, international agencies and donors would have been fighting to be the first to make it available many months, even years ago," Dr. Bailey said.

He said that studies have shown that circumcision of men in areas of high HIV prevalence would cost about $181 per person.

"Let's finally take the turn from the long road of contemplation to the highway of action," Dr. Bailey said. "We must make safe, affordable, voluntary circumcision available now."

"It is extremely clear that we have an intervention that is inexpensive and effective," said Julio Montaner, M.D., director of clinical activities at the British Columbia Center for Excellence in HIV/AIDS at the University of British Columbia. "It has to be rationally determined where the intervention will be most useful."

He said that circumcision and other proven HIV/AIDS interventions need to be implemented now. Inaction "could be considered as a crime against humanity," said Dr. Montaner, the president-elect of the IAS.

Dr. Bailey noted that in nations in Africa where HIV prevalence is the highest -- Swaziland, Botswana, Zimbabwe, and Zambia -- the rate of male circumcision is less than 20%. Where rates of HIV infection in sub-Saharan Africa are low, he said, circumcision rates exceed 80%.

"In fact, no country with nearly universal circumcision coverage has ever had an adult HIV prevalence higher than 8%, including countries such as Cameroon, where a 1997 survey found sexual behavior to be higher risk than that in countries with a prevalence of around 25%," he said.

Dr. Bailey cited studies that indicated that if 100% of men in sub-Saharan Africa opted for circumcision, 2 million infections and 300,000 lives could be saved over 10 years, and that 5.7 million infections would be averted over 20 years.

While acknowledging that a 100% circumcision rate is unrealistic, Dr. Bailey noted that other studies have suggested that a 50% rate in the South African city of Soweto could avert between 32,000 and 53,000 new infections over 20 years and HIV prevalence in that area would decrease from 23% to 14%.

In Rakai, Uganda, he said, a 50% uptake of circumcision would drive the infection rate to less than 1% and drive the epidemic into a declining state.

"The faster we scale up, the more infections we can prevent," Dr. Bailey said. The challenges to circumcision are multiple: It is only partially protective; there are safety issues such as making sure the procedure is done properly and that men do not engage in sex until complete healing has occurred; that it might be used as an excuse not to use condoms.

"But," he said, "circumcision is unique in that it is a one-time treatment, no booster is necessary, adherence once the procedure is complete, is complete. We must keep our eye on the prize: Male circumcision in east and southern Africa, and perhaps in other regions for selected populations, will save millions of lives."

The International AIDS Society did not require presenters to report potential conflicts or the sponsorship of research.

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